Incident investigation·November 7, 2025

On this day, Licensing Program Analysts (LPAs) Andrea Mendivil and Kimberly Lyman made an unannounced visit to conduct a case management visit. LPAs were greeted and granted entry into the facility. The Department received an Unusual Incident/Injury Report on 10/30/2025 for an incident that occurred on 10/27/2025. It was reported that an alarm from the back door on the 2nd floor of Memory Care was heard by staff at 10:25am. It was reported that care staff went to check the door and no one was seen. Staff then conducted a head count and found out Resident 1 (R1) was missing. It was then reported staff went searching through the Memory Care building and surrounding neighborhood. It was reported at 10:33am R1 was found sitting on a bench outside of a residential home approximately .5 miles away from the facility. R1 was escorted back to the facility and checked for injuries. It was stated R1 did not complain of pain and no injuries were noted. R1's family was notified. The facility noted they have conducted in-service training for elopements and reporting. Per review of R1's physician report dated 05/20/2025 R1 is diagnosed with dementia and is not allowed to leave the facility unassisted. During today's visit LPA's tested delayed egress exit gate and no staff responded to the gate alarms. Based on observations made deficiencies are being cited per Title 22 Division 6 of California Code of Regulations. ,An exit interview was conducted and a copy of this report, LIC 809-D, LIC 811 Confidential Names LIC 421IM and appeal rights were provided.